Consent to IPL Light Treatment

I authorize Dr. B. Alex Vakili and or his designee, to perform IPL (Intense Pulsed Light) skin treatments on me, including, but nnot limited to, the treatment of pigmented lesions (for example: sun spots, age spots and other skin discolorations), vascular nlesions (for example: red spots, leg veins and small spiders veins, but not varicose veins), wrinkles (rhytides), furrows, fine nlines, textural irregularities, non-ablative skin resurfacing, soft tissue coagulation, ablative skin resurfacing, and reducing or neliminating hair. I understand the procedure is purely elective, that the results may vary with each individual, and multiple ntreatments may be necessary.

I understand the following*
- The Palomar Icon Aesthetic System is a pulsed-light laser system that delivers a precise pulse of light energy that is absorbed by a chromaphore in the skin, for example, hemoglobin in the blood or pigment in a lesion, causing thermal reaction. All personnel in the treatment room, including me, must wear protective eye wear to prevent eye damage form this light energy.
- The sensation of light is sometimes uncomfortable and may feel like a moderate to severe pinprick or flash of heat. Anesthesia or sedation (calming medication) may be advised for laser skin resurfacing treatments. If the practitioner or physician elects to use an anesthetic to reduce discomfort during any light based treatment, all options and risks associated with the anesthetic will be discussed with me.
- The treated area may be red and swollen for 2-24 hours, or longer. Cooling the area after the treatment (for example: icepacks, topical gels) may help reduced discomfort and swelling.
- Common side effects include temporary redness (erythema) or mild “sunburn-like” effect that may last a few hours to 3-4 days, or longer. Other potential side effects include, but are not limited to: crusting, irritation, itching, pain burns, scabbing, swelling (edema), broken capillaries, bronzing, and acne or herpetic breakouts. There is also a risk of resulting unsatisfactory appears and failure to achieve the desired results.
- Pigment changes, including hyperpigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting 1-6 months, or longer, or permanently, may occur.
- Serious complications are rare, but possible, such as scarring, blood clots, skin loss, hematomas (collection of blood under the skin), and allergic reaction to medication or material used during the procedure
- I understand and accept that with skin resurfacing treatments there may be an increased length of social downtime associated with the level of treatment. There is also a chance of additional side effects, like balancing and significant redness.
- A barrier ointment may be used to cover the treated skin and keep it moist to avoid the skin drying out and being crusty or flaky. The barrier may make acne breakouts worse under the ointment.
- There is no guarantee that the expected or anticipated results will be achieved.
- Sun, tanning bed, or tanning lamp exposure, the use of self-tanning creams, and not adhering to the post treatment instructions provided to me may increase my chance of complications. I must avoid the sun (even on cloudy days), tanning beds, and sunless tanning lotions and use sunblock (at least SPF 30 or higher) after treatment.
- I should call my provider as soon as possible if I have any concerns about side effects or complications after treatment.
- I hereby consent to the administration of an anesthesia or sedation considered necessary or advisable for my procedure(s). I understand that all forms of anesthesia and sedation involve risks, and the possibility of complications, injury, and in very rare instances, death.
- I consent to photographs and digital images being taken and used to evaluate my treatment effectiveness, for medical education, training, professional publications or sales purposes. No photographs and digital images may be used, shared and displayed publicly without my permission.
- Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks as well as alternative treatment options have been explained to my satisfaction.
- Mild to serious complications and side effect are possible, including but not limited to, scars, white spots, dark spots, burns, redness, sunburn-like reaction, blistering, ulcers, crusting, itching, pain, bruising, skin whitening, skin darkening, skin infection, scabbing, swelling and failure to achieve the desired result. Complications may be temporary or permanent. Interruption of work, school, employment or lifestyle is possible.
- Treatment of spots and veins may not be permanent because new unwanted spots and veins can grow at any time after treatment. It is also possible that the treated spots and veins will reappear or regrow. Furthermore, some spots and veins will not go away with this treatment.
- Freckles may darken or lighten, and may temporarily or permanently disappear in treated areas.
- There is the likelihood of coincidental hair removal in the treated area, which may be temporary or permanent. It is also unlikely, but possible, that new or increased hair growth will occur in the treated area(s).
- I understand the importance of having an accurate diagnosis of pigmented lesions (any spot on the skin) by a physician prior to treatment to avoid delaying treatment of a skin cancer or pre-skin cancer. I understand that I am NOT being evaluated at this time for any skin condition.
- I understand there are no guarantees regarding results, complications or side effects associated with this treatment. No verbal guarantees of any kind have been made to me associated with this treatment.
- Pre and post treatment instructions have been discussed with me. I have read and understand the attached warnings. This treatment as well as alternative treatment options and the potential benefits and risks of each have been explained to my satisfaction. I have had all my questions answered.
- I freely consent to the proposed treatment. Treatment of any complications will be an additional cost at the client’s expense.
- I release Dr. Babak Alex Vakili, Lucencia Medical Spa and all of their employees and agents from all liability, including, but not limited to, their negligence associated with treatment.
Acknowledgement of Cancellation/Refund Policy
I understand that if I need or want to change or cancel an appointment with Lucencia Medical Spa, I must do so during Lucencia’s regular business hours. I further understand that I must do so no less than two business days before the appointment.
Furthermore, I understand that I must make this change with one of Lucencia Medical Spa’s staff members in person or by phone. Leaving a message on the answering machine will not be sufficient to cancel or change my appointment. I further understand that if I fail to abide by this cancelation policy I will be responsible for a late cancellation fee of $50.00, which is to be paid in full immediately. Failure to pay this late cancelation fee will result in additional expenses for me including, but not limited to, interest, collection costs and attorney fees.
*We do not give refunds on our services or products.
*We do not take back products.
*All packages must be paid upfront to receive discount offers.
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407-760-1554

Consent to IPL Light Treatment

Acknowledgement of Cancellation/Refund Policy

Optional Information

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